Your health and total wellness, our top priority.

Pain & Health Problems Survey

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  • CHECK OFF WHICH OF THE FOLLOWING OCCURED AT LEAST ONCE IN THE PAST 30 DAYS

  • Please enter a number from 1 to 10.
  • We will call to confirm your appointment.

  • THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT. OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION, OR TREATMENT.